- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $3,235.94
| Professional | | $2,754.23 | $2,754.23 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $169.82 / $177.83
| Professional | | $169.82 | $169.82 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,096.48 / $1,621.81
| Facility | | $794.33 | $1,096.48 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,513.56
| Professional | | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,096.48 / $1,621.81
| Facility | | $812.83 | $1,096.48 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,513.56
| Professional | | $1,513.56 | $1,513.56 | $1,513.56 |